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"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

This installment: A noteworthy case study.

Why did a breast cancer patient in her 60s suddenly develop discolored itchy and tingling patches on her hands and ankles? That's what Chung-Hsing Chang, MD, PhD, of Hualien Tzu Chi Hospital in Taiwan, and colleagues needed to determine when the patient presented to the dermatology clinic.

As the team described in , the patient was undergoing weekly intravenous treatment with paclitaxel for stage IIB (T2N1M0) invasive ductal carcinoma of the right breast, and the cutaneous lesions developed about a week earlier after seven infusions. She had three infusions of 80 mg/m², followed by four of 70 mg/m².

Physical examination showed "dusky red to violaceous patches with desquamation on the wrists and dorsal surface of both hands and near the Achilles tendon," Chang and co-authors wrote. There was also hyperpigmentation affecting all of the patient's fingernails and toenails. In addition, the patient had onycholysis on her toenails; the palms of her hands and soles of her feet remained unaffected.

The team diagnosed the patient with "toxic erythema of chemotherapy -- specifically, periarticular thenar erythema and onycholysis (PATEO) syndrome -- secondary to paclitaxel."

Chang and co-authors started the patient on topical treatment with emollients and clobetasol ointment, 0.05% twice daily. She completed her remaining 5 chemotherapy sessions at a reduced dose of 60 mg/m² of paclitaxel. Clinicians noted improvements in her skin condition within 2 weeks, with no symptom exacerbation.

Discussion

"Toxic effects occurring on the skin of the Achilles tendon and hand extensor tendons is pathognomonic for the presence of taxanes in chemotherapy," Chang and colleagues pointed out. They noted that early recognition and management of the toxic effects associated with these agents can reduce morbidity and allow patients to continue with treatment.

The taxane class of medications, such as paclitaxel and docetaxel, are commonly used to treat several types of cancer. Dermatologic of these treatments are relatively common, the group wrote, citing data suggesting that alopecia, nail changes, and erythema of the face or extremities affect up to 89% of taxane-treated patients.

This patient's presentation of acral erythema with palmoplantar dysesthesia is known as hand-foot syndrome, a condition thought to affect about 5-10% of patients receiving treatment with taxanes, the team said.

Hand-foot syndrome, in which erythematous-violaceous patches appear on the dorsal surface of both wrists and hands along with nail hyperpigmentation, is just one manifestation of toxic erythema of chemotherapy, Chang and co-authors explained. "The term toxic erythema of chemotherapy encompasses a spectrum of nonallergic, intersecting reactions observed in patients receiving chemotherapy."

This patient's case of PATEO syndrome, however, represents a of hand-foot syndrome associated with taxane-based chemotherapy. The syndrome is marked by its "unique distribution that spares much of the palms and soles, and instead presents with violaceous coloration of the dorsum of the hands (especially thenar and hypothenar eminences), wrists, and Achilles tendon area," the team wrote.

"In up to about 44% of cases, the nails may also separate from the underlying nail bed, and additional nail changes that can be associated with taxane chemotherapy include Beau's lines, subungual hemorrhage, nail pigmentation, acute paronychia, and splinter hemorrhage," Chang and co-authors noted.

They explained that the severity of PATEO syndrome often reflects the cumulative taxane dose and the dosing interval. Symptoms usually respond to regional cooling and application of topical corticosteroids, and in severe cases, the chemotherapy dose or interval might be adjusted.

Indeed, reducing the chemotherapy dose proved to be helpful in the case of this patient.

Read additional installments in this series here.